Dengue Infection In The Pregnant Woman

Although many arboviruses are known to cause fetal death, premature birth, and teratogenic changes in humans and animals, the few reports of fetal malformation or wastage from dengue infection are poorly documented, and the evidence is contradictory. Despite the small number of reported cases during the perinatal period (9 reports that included 20 mother-infant pairs), it is nevertheless evident that there is potential for severe disease with dengue infection in the mother and the newborn (21-29).

The paucity of documented patients with dengue during pregnancy suggests that the most common clinical result in the mother is an asymptomatic or minimally symptomatic infection. It is also possible that most cases do not result in reportable complications. In the last four decades after laboratory diagnostic methods became more generally available, case reports of pregnant patients during the perinatal period with hemorrhage and probable or confirmed dengue infection have been published. Hemorrhagic manifestations are usually mild and include mucocutaneous (e.g., petechiae in buccal cavity and in subconjuntivas, nose or gum bleeding) or subcutaneous bleeding (e.g., petechiae in skin, easy bruising). Severe bleeding has also been documented.

In 1970, Moreau and colleagues described a 25-year-old Tahitian patient with gum bleeding, uterine hemorrhage, and spontaneous abortion (21), and in 1989, Taechakraichana and Limpaphayom described a 20-year-old Thai patient with DHF at 23 weeks of gestation with satisfactory recovery (22). Among patients during the perinatal period, a 32-year-old mother with serologic evidence of acute dengue infection at term was reported from Thailand in 1994. She required cesarean section because of previous cesarean intervention and developed continuous bleeding from the surgical wound, resulting in a large blood collection in the lower uterine segment (23). In 1997, Chye et al. reported two laboratory-positive dengue patients at 36 and 38 weeks of gestation in Malaysia (24). One patient developed DHF with severe preeclampsia and required induction of labor. The other patient only developed petechiae and epistaxis. In the same year, Bunyavejchevin et al. reported two mothers from Thailand with dengue infection during the perinatal period. Both of these had mild hemorrhagic manifes tations, and one case developed DHF also complicated by severe preeclampsia (25). In 1999, Carles also reported four mothers in French Guiana with dengue infection within 1 week of delivery (26). Although low platelet counts were reported, no hemorrhagic complication was recorded.

Reports of dengue infections have come from Guadeloupe (one mother developed severe thrombocytopenia, giving birth via cesarean section, and the other had preterm labor; mothers and infants recovered without complications) and from Thailand (thrombocytopenia with and without hemorrhagic complications) (27-29).

In a review of laboratory-positive cases of mother-infant pairs in Puerto Rico from 1994 to 2003, four cases of maternal-fetal transmission were documented. All mothers were positive for anti-dengue IgM antibody, and infants were diagnosed by virus isolation, polymerase chain reaction, or anti-dengue IgM detection (CDC, unpublished data, 2003). In three of the four cases, the disease in the mother was only suspected following occurrence of symptoms in the newborn. All mothers showed fever, and as in other groups with dengue, leukopenia and thrombocytopenia were present in the four pregnant women.

Preeclampsia and eclampsia postpartum have been reported in 3 (13%) of the 24 cases of maternal dengue infection reported during the perinatal period. Of the three cases, two also fulfilled the diagnostic criteria for DHF. Because DHF is associated with thrombocytopenia and elevated liver enzymes, it must be differentiated from the HELLP syndrome, in which hemolysis, elevated liver enzymes, and low platelet count are characteristic features. Although hemolysis does not occur in DHF, early diagnosis and differentiation of DHF and HELLP syndrome are critical. Any pregnant woman with a history of exposure to dengue virus who presents in the third trimester with clinical findings compatible with a suspected dengue case should be evaluated with a CBC, liver function tests, and specific tests for dengue infection.

In the evaluation of a pregnant woman with suspected dengue, the medical history must elicit information about international travel history to tropical or subtropical areas and past exposure to dengue infection. The physical examination should include the search for hemorrhage (including tourniquet test), hypotension, or increased vascular permeability (ascites or pulmonary effusions, hypoalbuminemia, or hypoproteine-mia). Peripheral edema is not a useful indicator of increased vascular permeability because swelling may be present in up to 30% of normal pregnancies. Close follow-up of blood pressure and hydration status are mandatory. Evaluation of fetal well-being is also required in all cases. Fetal movements, nonstress test, or uterine biophysical profile could be useful measures of fetal well-being.

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